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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PAY MASTERFILE RECORD INFORMATION FORM RF NT CE�c ❑'New EH Pro-ram�aI Existin a .Facilit ❑New EH Program and New.Facili O `'0 FacilityID iO�S Program Record ID CT 06 7020 SAN V Ao&**Q E . NwY 12-0 �SCAtON, CJl R5% VIRQU/1V C (Please check the appropriate description and specify size,number of units and pertinent Information:) LTNOF aetTO(JN7y FOOD PROGRAM,(1600) _ ❑ Restaurant Seating Capacity_ Square Footage - Food Handlers Course required: Yes ❑ N_O ❑ n Commissary ❑ Dry storage only ❑ with Food Preparation - 0-Vending Machines Number of Units. - -Square footage (P I"g- ❑ W/MeatMarket only ❑ Multiple Departments 11 Prepackaged Goods Only ❑ Mobile Food Vehicle—Make...: -Vehicle Type Color Registration# License# Slicker# ❑ Mobile Food Prep Unit-Make Vehicle Type - Color Registration# . - -- _ License#- Sticker# ❑ Temporary Food Facility--Dates of operation from _ to - .. __.. ❑ Ice plan Produce Stand 1:1 Special Event--Dates of operation from - to ❑ CFO ❑A❑ 13 DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit_ CUPA ❑ Hazardous Materials Business Plan(1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program.2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200) —> Tons Generated Per Year ❑ Tiered Permitting Facility--> ❑CA(2232) ❑ CE(2233,2234,2235,2237) ❑ PBR(2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST)(2800) Number of ASTs ❑ Underground Storage Tank Program (UST)(2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel--Number of Units ❑ Jail or Exempt Institution---Number of Units Employee Housing(2700) Use Employee Houslno/Labor Camp Aoollmdon Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPLISEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPLISEP Cleanup Site ❑RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility_ ❑ Pool ❑Spa ❑Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL pROGRAIN(4000) ❑ Poultry Farm---Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM(4100) ❑ Body Art Practitioner Reg(4110) ❑ Mechanical DSPS Notification(4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization(4121) ❑ Body Art Temp Event Co-ord(4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets--Number of Units SOLID WASTE PROGRAM(4400) ❑ Landfill ❑ Transfer Station ❑ Ag/Cannery Waste Site ❑ Sludge/Ash Site ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site ❑ Refuse Vehicles is of Urals) ❑ Dumpsters>20 cu yd(xorunits) ❑ Farm/Ranch Cleanup Site MEDICAL WASTE PROGRAM(4500) I7 Primary Care 13 Acute Care ❑ Skilled Nursing ❑ Large Generator 0 Small Generator ❑ Limited Hauler ❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility 112-10 011 -60 ❑ >60 generators PUBLIC WATER SYSTEM PROGRAM(4600) Use PWS EHD 46.02-003 Blue Application Form EMERGENCY NOTIFICATION FORTHIS FACILITY ANDIOR PROGRAM PROGRAM ELEMENT FE a/6. op ❑ Surcharge F E ❑ Other FEE INSPECTOR# PERMIT VALID /a 2-6 t0 .3I AT_ ❑ Food Handier ❑ Check# f 5. AMOUNT PAID 12!3.1ob Date A L 2-6 INVOICE# ❑ Cash REVIEWEDBY ACCOUNTING OFFICE Date 1191112 48-02-034 IL MASTERFILE REeOR0 INFORMATION PINK 1!23113